Phase-specific wound management of decubitus ulcer
Transcription
Phase-specific wound management of decubitus ulcer
medicaledition PAUL HARTMANN Asia-Pacific Ltd. 16/F Unit 1608 Kerry Cargo Centre 55 Wing Kei Road Kwai Chung NT Hong Kong ISBN 3-929870-44-4 curr At a time of r ing new ar shown modern tr and ar HARTMANN medicaledition – Phase-specific wound management of decubitus ulcer PAUL HARTMANN AG Unit P2 Parklands Heywood Distribution Park Pilsworth Road Heywood, Lancs OL10 2TT United Kingdom Phase-specific wound management of decubitus ulcer B34 (0106) 086 XXX/X PAUL HARTMANN AG P.O. Box 14 20 D-89504 Heidenheim Germany Wound Management Published by PAUL HARTMANN AG D-89522 Heidenheim http://www.hartmann.info Concept, design, editing and production: CMC Medical Information D-89522 Heidenheim Scientific supervision: Prof. Dr. med. Walter O. Seiler, University Geriatric Clinic; Basel Cantonal Hospital Friedhelm Lang, Head of Surgical Department Leonberg District Hospital © PAUL HARTMANN AG April 2006 ISBN 3-929870-44-4 Translated from the German edition (ISBN 3-929870-41-X) Paper bleached by a chlorine-free process Table of contents Preface 5 Development of decubitus – a multifactorial process – Common sites of decubitus ulcer formation – Decubitus hazards and risk factors – Classification and degrees of severity of decubitus 6 9 10 18 Management of decubitus – general principles – Relief of pressure as the basis of all treatment – Phase-specific moist wound treatment – Identification and treatment of factors interfering with wound healing 20 27 30 39 Hydroactive wound dressings for phase-specific, moist wound treatment – TenderWet – wound pad with superabsorber – Sorbalgon – calcium alginate dressings with excellent conformability – PermaFoam – hydroactive foam dressing – Hydrocoll – absorbent hydrocolloid dressing – Hydrosorb – transparent hydrogel dressing 46 48 53 57 60 63 Nursing activities for decubitus prophylaxis 70 Supplementary aids for treatment and nursing care 73 Glossary and list of key terms 77 References and list of illustrations 79 [2.3] Preface One of the most serious complications of immobility is the development of a decubitus ulcer (pressure ulcer, pressure sore). For the person affected, it is always a serious health impairment, quite apart from the enormous amount of nursing input and cost involved in treating pressure sores. The problem of pressure ulcer impacts all areas of nursing care and it has come to be regarded as an indicator of the quality of nursing care if a pressure sore does not develop. Under this aspect, increased attention has therefore been devoted in recent years to the problems associated with pressure sores. It has been attempted in scientific and clinical studies to elaborate guidelines for practicable prophylactic and therapeutic activities and establish them as standard practices. Despite these efforts, pressure ulcer with an annual incidence of 150,000 cases in Stages III and IV still remains a major problem for a number of reasons. The growing number of elderly and aged persons of restricted mobility and often pronounced multimorbidity is a significant factor in this respect. Especially in the elderly, the management of pressure ulcer presents a challenge which all too often remains unmastered. This HARTMANN medical edition provides essential knowledge relating to the pathogenesis of pressure ulcer and sets out successful therapeutic principles which, if applied consistently, promise good prospects of a cure. It should nevertheless be emphasized that the management of decubitus ulcer requires both knowledge and skill and a high degree of discipline on the part of all those involved in delivering wound management. In many cases, traditional methods and approaches have to be reconsidered; the widespread practice of polypragmasy is to be avoided in favour of consistently structured therapeutic concepts. [4.5] Development of decubitus – a multifactorial process Immobility and the resulting abnormally long period of exposure to pressure is without doubt the central causal factor in the pathogenesis of pressure ulcer. However, a large number of other risk factors specific to individual patients also contribute to the development of pressure sore, which makes the process highly complex and difficult to define. Nevertheless, a program of treatment and nursing care will attempt to address the patient’s needs on a holistic basis and not merely treat the pressure ulcer as an isolated phenomenon. A decubitus ulcer is defined as damage to the skin resulting from persisting local exposure to pressure. Its process of development may be outlined in the following general terms: When sitting or lying, the human body exerts pressure on the surface supporting it, which in turn exerts counterpressure on the area of skin bearing upon it. The degree of counterpressure varies depending on the hardness of the supporting surface, but is usually above the physiological capillary pressure of approx. 25-35 mmHg arterial. For short periods, the skin can tolerate exposure to even higher pressures. If the pressure persists, however, compression of the capillaries carrying the blood in the area of skin affected results in a reduction of blood flow and oxygen deficiency (hypoxia). The body responds to this incipient damage by producing pressure pain as a warning sign, which causes a healthy person capable of movement to change position to relieve the load on the compressed area of skin. Even slight movements are sufficient to interrupt the exposure to pressure and stimulate the impaired blood circulation back into activity. This pressure pain mechanism also functions involuntarily during sleep, which is why persons capable of movement do not develop a pressure sore. If these persons are unable to perceive the warning pain, however, for example because of unconsciousness, anesthesia, severe dementia and/or if they are no longer strong enough to move unaided in response to pain, the compression of the skin continues. The impairment of blood circulation worsens and leads to an accumulation of toxic metabolism products in the tissue accompanied by an increase in capillary permeability, vasodilation, cellular infiltration and edema. If the pressure on affected area of skin is then removed completely, the cells are still capable at this point of regenDevelopment of decubitus [6.7] Causes of pressure sore: For short periods, the skin can survive exposure even to heavy pressure without being damaged. If the pressure persists, however, the affected skin cells become completely ischemic because of the increasing impairment of blood circulation and the skin cells die. Pressure / pressure exposure time local impairment of blood flow oxygen deficiency / increase in toxic metabolism products increase in capillary permeability, vascular dilatation, cellular infiltration, edema formation blister formation complete ischemia, irreversible death of skin cells Ulcer / necrosis erating completely because the inflammatory responses promote the elimination of the toxic metabolism products. If exposure to pressure remains, however, the worsening ischemia and hypoxia result in irreversible death of the skin cells with necrosis and ulcer formation. The main causes of pressure ulcer are thus the factors pressure x time acting on a given area of skin. Clinically relevant factors in this respect are the degree of pressure and the length of time. A high degree of pressure results in tissue damage sooner than a low degree. As regards the factor time, high pressure peaks over a short period are well tolerated by the skin. In contrast, persisting pressure only slightly above the capillary pressure damages the skin after only a few hours. This fact has practical consequences: For prophylaxis, patients at risk of pressure ulcer should be repositioned after a period of not more than two hours. It should always be remembered, however, that this average tolerance range of the skin is subject to considerable variations which are determined by the individual patient’s risk factors such as the degree of immobility, the condition of the skin, various basic illnesses etc. What specific risk factors are involved and what role they play in causing pressure sores are considered in the section „Decubitus hazards and risk factors“ on page 10 onwards. Common sites of decubitus ulcer formation Depending on where the skin is exposed to pressure, a pressure ulcer can develop anywhere on the body. The risk is greatest at those sites, however, where the bearing pressure of the body and the counterpressure exerted by the supporting surface act perpendicularly on an area of skin located over convex skeletal regions which have little pressure dispersing elastic muscle and subcutaneous fatty tissue. Accordingly, the classical sites of predilection (about 95 % of all pressure sores develop here) are the sacral region, the heels, the ischial bones, the greater trochanter and the lateral malleoli. Examples of “classical” sites of predilection for pressure sores: 1) Sacral region 2) Heel 3) Trochanter 4) Lateral malleolus 1 2 3 4 Development of decubitus [8.9] Another characteristic feature of pressure acting on convex bony contours is that the pressure increases from the larger skin surface towards the deeper-lying convex bone surface. This results in necroses in the subcutaneous fatty tissue and muscles until, often not until several days have passed, the skin ulceration becomes apparent. This lesion may be relatively small and does not always reflect the already considerable damage in the deeper regions. Sometimes the skin shows only reddening and slight damage of the epidermis (“closed decubitus”). Besides the pressure acting perpendicularly on an area of skin, shear forces are probably also involved in causing pressure sores. Shear is a term denoting tangential shifts in the skin layers in relation to each other, which also constrict and compress the blood vessels. Tangential forces may be expected to arise particularly in the sacral region, for example when the patient is pulled instead of lifted into a new position or slides in bed due to inadequate support for the feet. Experimental studies on the effects of perpendicularly acting shear forces allow the conclusion that when a combination of shear forces and pressure is present, even slight pressure is enough to reduce the oxygen partial pressure in the tissue to a critical level (Bennet et al., von Goosens et al.). Decubitus hazards and risk factors The most important risk factor is immobility, since it is causally related to the duration of pressure exposure. The hazard increases with the patient’s degree of immobility. The commonest pressure sore localisations Pressure ulcer develops preferentially over bony prominences hardly cushioned by muscle and subcutaneous fatty tissue. These are 䢇 in dorsal position: sacral bone and coccyx, heels and Achilles tendons, elbows, shoulder blades and occipital bone 䢇 in abdominal position: frontal bone, elbows, breastbone and costal arches, iliac crest, kneecaps and tips of the toes 䢇 in lateral position: great trochanter, ear and zygomatic bone, lateral ribs, shoulder joint, iliac crest, inner and outer knee joint, calf bone and lateral malleolus 䢇 in sitting position: ischial tuberosity, occipital bone, spine and heels; if poorly supported, there is also a potential hazard from shear forces Development of decubitus [10.11] Total immobility: If spontaneous movements are no longer possible, the patient is absolutely at risk. Total immobility is seen, for example, in unconscious, anesthetised or completely paralysed patients. The patient’s age is irrelevant. Relative immobility: A high hazard potential is present because spontaneous movements are more or less restricted, for example due to sedation, fractures, severe pain, multiple sclerosis, paraplegia, hemiplegia and disorders of sensitivity of widely varying origin, such as polyneuropathy. It should especially be remembered that the risk factor immobility is influenced by general nursing care activities and is thus inevitably subject to diurnal variations. For example, whereas the immobile patient is repeatedly moved during the day for basic care activities and feeding, during the night there is usually a critically long period of immobility. These problems are observed especially in association with age related reductions in mobility, which also results in a critical decrease in spontaneous body movements (motility) during the night. When additional diseases are present, such as fever (pneumonia) or severe pain, the number of nocturnal body movements may decrease to practically zero, and without prophylaxis the patient is at risk of developing a pressure sore. Secondary risk factors Further secondary risk factors include all states and illnesses which affect especially the function and resistance of the skin. The skin then becomes more sensitive to pressure and even brief periods of exposure to pressure can result in damage. These risk factors include: Insufficient blood supply to the skin: Insufficient blood supply to the skin means a reduced supply of oxygen and impaired metabolic processes in the skin cells, with the result that the skin’s tolerance of hypoxia also decreases. Blood perfusion can be impaired by a multiplicity of factors, such as hypovolemic, cardiogenic or septic shock, low blood pressure, dehydration, heart failure, diabetes mellitus, arteriosclerosis etc. Fever: Fever leads to an intensified metabolism of the skin cells and an increased oxygen demand, as a result of which inadequate blood perfusion already occurs at subdecubitogenic pressures. Moreover, in febrile states the immobility of geriatric patients is often worsened, and fever is therefore classified as the most important secondary risk factor for this patient population. Incontinence: Moisture and the aggressive decomposition products of urine and/or feces irritate and soften the skin, which is also highly bacterially contaminated. If these effects are not mitigated by the use of adequate skin care and provision of appropriate aids, the upper layers of skin become macerated, lowering the skin’s resistance to pressure. Incontinence is thus another risk factor affecting especially elderly, bedbound patients. It is, however, incorrect to assume that incontinence alone can cause a pressure sore. The causal factor in pressure ulcer is pressure, and incontinence is a contributory factor. Debilitated general condition: Chronic or severe illnesses, malignant processes, infections, malnutrition characterized by protein, vitamin and zinc deficiency, anemia, exsiccosis, cachexia etc. also increase the risk of pressure sore. Many of the diseases greatly restrict the patient’s mobility/ motility and impair the skin’s metabolism. Development of decubitus [12.13] Physiological aging of the skin: Independently of coexisting diseases, geriatric skin is itself a risk factor for developing a pressure ulcer. The age related depletion of cellular and fibrous elements makes the skin generally thinner, and the skin’s connective tissue loses elasticity. As a result, the skin’s ability to tolerate mechanical loading decreases, and exposure to pressure can lead to the formation of a pressure ulcer within a very short time. Operation-specific risks The primary causes of intraoperatively acquired pressure ulcer are essentially the same as those in other areas of medicine and nursing: pressure (poorly padded or unpadded operating tables acts over a period of time (operation time) on certain areas of the patient’s skin and damages them. However, there are also secondary, operation-specific risks due firstly to patients themselves and secondly to the surgical procedure. Besides the factors already described, such as effects of acute and systemic diseases, fever, age etc., risks presented by patients themselves include existing skin damage, e.g. due to confinement to bed before the operation or extension treatment until the patient is capable of being operated. Risks arising during the surgical procedure may include: anesthesia-induced loss of skin tone, incorrect repositioning (especially of the extremities, which may lead to extremely high pressure points), extreme shear forces and exposure to pressure during treatment of fractures on the extension table, assistants leaning on the patient for support, patient hypothermia, incorrect use of disinfectants (especially in the coccyx region, which can also lead to excessive cooling of the skin because iodine- and alcoholcontaining disinfectants collect here at the lowest point), long vessel clamping times or excessively long bloodless times. Risk factors for decubitus Primary risk factors that reduce motility and lead to total/relative immobility Neurological disorders with paralysis (all): cerebrovascular stroke, hemiplegia, hemiparesis, paraplegia, tetraplegia, comatose states of any origin ■ Surgical interventions: anesthesia (premedication, anesthesia, recovery phase), long operation times ■ Psychiatric illnesses and psychotropic medications: acute psychoses such as catatonia and acute depression, sedative medications like neuroleptics, benzodiazepines and similar ■ Consumptive diseases and severely painful states ■ Secondary risk factors that especially reduce tissue tolerance Factors reducing intravascular pressure Arterial hypotension: shock (hypovolemic, septic, cardiogenic), overdose of antihypertensive agents ■ Dehydration: diuretics, diarrhea, summer heat ■ Factors reducing oxygen transport to the cell Anemia: Hemoglobin < 9 g/dl ■ Peripheral arterial occlusive disease ■ Diabetic microangiopathy ■ Hypotension, bradycardia ■ Factors increasing oxygen consumption in the cells Fever: > 38 °C ■ Hypermetabolism ■ Infections, cytokinemia ■ Factors resulting in nutrient deficiency in the cells Malnutrition: deficiency of protein, vitamins, minerals, trace elements ■ Cachexia: immobility due to muscular weakness and catabolism ■ Lymphopenia associated with malnutrition: immune deficiency, disorder of wound healing ■ Factors weakening the skin’s resistance Geriatric skin: thin, atrophic, with few immune cells ■ Skin diseases: eczema, candidiasis ■ Dry, cavernous skin: promotes bacterial and fungal skin infections ■ Pressure-damaged, reddened skin: as a sign of harmful shunt circulation ■ Macerated, softened skin: in incontinence due to breakdown products of urine and feces ■ Heat, inflammatory reddening: circumvention of nutritive microcirculation ■ Steroid induced skin atrophy: thin, easily injured skin ■ (Source: Seiler, 2002) Development of decubitus [14.15] Assessment of hazard from pressure ulcer Estimating each patient’s risk of developing a pressure ulcer is the first step in planning of prophylaxis. This activity may be assisted by using various rating scales such as the Norton scale, the Waterlow scale or the Braden scale. In Germany, the extended Norton scale is widely used in medical nursing, while the Waterlow scale relates more specifically to the risks of surgical patients. The Braden scale is used more commonly in the USA. Common to all these scales is that they take similarly into account the patient’s mental and physical state as well as their level of activity and mobility, and are thus all useful instruments. It should be noted, however, that the assessment of hazard from pressure ulcer and hence the delivery of adequate prophylaxis should not only begin at the stage when reddening has already developed at the risk sites. Furthermore, the points score should be checked at regular intervals to allow timely identification of changes and a suitable response to be made in terms of modifying activities. The assessment of pressure ulcer hazard is thus part of a thorough program of documentation. Physical state Incontinence Activity Mobility Psychological state 4 good 4 none 4 no assistance required 4 completely 4 clear 3 a little 3 sometimes 3 possible with assistance 3 hardly restricted 3 apathetic / disinterested 2 poor 2 usually urine 2 wheelchair required 2 very restricted 2 confused 1 very poor 1 urine and feces 1 bedbound 1 completely restricted 1 stuporous Willingness to cooperate Age State of the skin Concomitant diseases 4 completely 4 < 10 4 normal 4 none 3 few 3 < 30 3 scaling dry 3 immune weakness, fever, diabetes, anemia 2 partially 2 < 60 2 moist 2 MS, Ca, elevated hematocrit, obesity 1 none 1 > 60 1 allergy wounds, fissures 1 arterial occlusive disease According to the original Norton scale (above) patients with a points score of 14 and less are to be classified as being at risk of developing a pressure sore. In the extended Norton scale (original scale above + extension below, devised by C. Bienstein et al.) which allows a more differentiated assessment of the patient’s status, a risk of pressure ulcer is present at a score of 25 points and less. Prophylactic measures must be planned and implemented immediately. Development of decubitus [16.17] Classification and degrees of severity of decubitus Considering the origins of pressure ulcer, it is clear why the ulceration develops in stages: The longer the area of skin is exposed to pressure, the more severe the tissue damage becomes. The classification of degrees of severity is therefore based on an evaluation of which layers of skin have already been destroyed by the pressure damage. Various decubitus classifications are used, such as Daniel’s classification into five degrees of severity, which is used particularly in the surgical field, or the most commonly used classification into four degrees of severity developed by the “National Pressure Ulcer Advisory Panel” in 1989. Stage I: Sharply defined area of reddening on intact skin that, when pressed, is “non-blanchable”. Indicative signs may also include hyperthermia of the skin, induration or edema, and persons with dark skin coloration may show depigmentation. With consistent pressure relief the reddening pales after several hours or days, depending on the severity of the prior impairment of blood perfusion. Stage II: Partial loss of epidermis as far as the dermis. This is a superficial ulcer which may manifest clinically as an abrasion, blister or shallow crater. Stage III: Damage to all layers of skin (epidermis, dermis and subcutis), which may extend as far as the fascia beneath the skin, although the fasciae are not yet affected. Clinically, the pressure ulcer looks like an open sore with or without undermining of the surrounding tissue. Epidermis Stage I Dermis Classification of the severity of pressure ulcer is based on which tissue layers have already been destroyed by exposure to pressure. Stage II Subcutis Stage III Muscles, Tendons, Bones Stage IV Stage IV: Loss of skin involving the entire skin thickness with extensive tissue necrosis and damage to muscles, tendons and bones. Undermining and pocket formation are also commonly seen. Identifying the current stage of the ulceration may be difficult in practice. For example, skin damage in Stage I is often not reliably assessed, especially in patients with dark skin pigmentation. As already mentioned, a Stage I may already be a sign of deeper lying damage in the form of a “closed decubitus”, for example secondary to intraoperative exposure to pressure. An ulcer covered with scab and necrotic debris may also impede correct evaluation unless the devitalised tissue has first been removed. The assessment of pressure sores may also be difficult in patients with plaster casts and other orthopedic devices. Development of decubitus [18.19] Management of decubitus – general principles A decubitus ulcer not infrequently takes many months to heal and in elderly persons often presents a challenge that remains unmastered. Not least, this may be because of the extreme difficulty in translating the complexity of pressure ulcer causation and chronic wound healing into easily understandable, standardized therapeutic concepts. Medicine and nursing are therefore called upon to develop a treatment which as far as possible takes into account the individual patient’s specific disease and life circumstances. Because so many influencing variables and risk factors are present concurrently and have to be given adequate consideration in the management of pressure sore, it is recommended to pursue a consistent approach based on a treatment schedule. This schedule should not be seen as a rigid structure, but should rather take the form of a carefully assembled check list helping to ensure that nothing is overlooked. A quality assured management program will include the following steps: ■ Initial assessment of the overall situation, both of the local state of the ulcer and the patient’s general status ■ Completely relieving the pressure on the damaged area of skin to restore the blood supply. ■ Phase-specific moist wound treatment with debridement and infection control; the possibilities of plastic surgical defect coverage are to be explored and applied if appropriate ■ Adjuvant therapies to improve the patient’s general condition and nutritional status and to provide adequate pain control; factors interfering with wound healing are to be treated. ■ Careful documentation for quality control and security under liability law aspects. Assessment of decubitus ulcer In the initial assessment, the ulcer is evaluated according to localization, stage, size (length, breadth, depth), pocket formation, undermining, exudate flow etc. The schedule provided on page 25 offers a possible approach to initial assessment. The ulcer localization is sketched in the drawing field. It is also recommended to include a colour photograph of the ulcer in the documentation. To exactly determine the size and volume of an ulcer, volumetric measurement of the wound is a practicable approach requiring little time and effort. The wound is covered with a foil and filled with sterile liquid (e.g. Ringer’s solution) using a syringe. Management of decubitus [20.21] Volumetric measurement of the wound is an exact and simple method of determining the size and volume of a wound. The wound is covered with a foil (left) and filled with sterile liquid using a syringe (right). The number of injected ml or ccm correspond to the volume. The injected ml or ccm represent the volume. Volumetric measurement should also be performed repeatedly during wound healing, since the values recorded are prognostically valuable and represent valuable objective data for inclusion in case records. As a positive secondary effect, volumetric measurement is also useful as a form of wound irrigation. If it is known under what circumstances and through the application of what pressure the ulcer developed, these details are also to be entered in the initial assessment: For example, application of pressure during surgery, in association with a febrile disease, as the result of a fall and lying too long at home etc. This information is particularly important for assessing the continuing risk of developing a pressure sore. Assessment of the patient’s status The assessment of the patient should include the general condition, possible complications and concomitant diseases, the nutritional status, the severity of any pain, but also a careful inventory of the psychosocial situation. General physical condition: Wound healing is not merely a local process, but is linked to processes in the entire body on many levels; consequently, an improvement in the patient’s general condition can have a major influence on wound healing. Initial assessment of overall situation Course of treatment for decubitus ■ Localization of the ulcer, severity, general condition of the wound ■ Evaluation of the patient’s status, compliance Treatment Causal therapy ■ Complete relief of pressure to restore the blood supply throughout the treatment period until the ulcer has healed Local ulcer therapy ■ Adequate surgical debridement ■ Infection control, when appropriate ■ Moist dressing treatment for further wound cleansing, conditioning and epithelisation ■ Plastic surgery techniques as appropriate Adjuvant therapies ■ ■ ■ ■ Improve the general condition Improve the nutritional status Pain management Identify local and systemic factors interfering with wound healing and eliminate them as far as possible Ulcer healing? yes no Course of treatment for decubitus ulcer supervision and continuation of therapy according to treatment schedule Careful monitoring of activities (especially whether pressure relief is adequate) Management of decubitus [22.23] Depending on the patient’s age and illness, however, an improvement in the general condition cannot always be achieved within a short time, and may even be severely impaired, for example in multimorbid geriatric patients. In practice, the necessary data can be obtained from the patient’s medical record and if not, are to be elicited by taking a careful and comprehensive medical history and conducting a physical examination. With pressure ulcers, moreover, the physician should be alert to the possibility of complications, such as endocarditis, meningitis, septic arthritis, pocket and abscess formation, malignant processes in the ulcer area, and for systemic complications of the topical therapy, such as iodine toxicity or allergy. Serious complications associated with infection include osteomyelitis, bacteremia and generalized sepsis. Nutritional status: Numerous studies have established a relationship between the poor healing tendency of pressure sores and malnutrition. Cachectic states associated with protein deficiency, however, are observed particularly often in elderly persons, and the nutritional status should therefore be evaluated at regular intervals in these cases. Elderly patients are often also suffering from zinc deficiency which can also lead to delays in wound healing and should therefore be checked. Malnutrition should be treated, taking into account the patient’s wishes, by providing adequate dietary intake with an increased protein content and sufficient vitamins and minerals. The requirement for nutrients in illness and catabolism in the elderly is reported as follows per kilogram of body weight and per day (Seiler, 2001): 30 to 40 kcal, 1.5 g proteins, 1.0 g fats, 10 mg vitamin C, 15 mg calcium, 0.5 mg zinc, vitamin B12 parenterally substituted (target dose 10 mg total or 0.15 mg per kg body weight within one month; Interval: every 3 days 1 mg i. m.) Record form for assessment of decubitus Name Age Date / time of recording Size Length breadth depth Severity / structures affected ❏ Stage I: ❏ Stage II: ❏ Stage III: ❏ Stage IV: skin reddening with intact epidermis superficial ulcer, partial loss of epidermis as far as dermis deep, open ulcer, damage to all skin layers as far as the fasciae extensive tissue necroses, damage to all skin layers including muscles, tendons and bones Yes Pocket formation Undermining Necrotic tissue: Exudate: Granulation: No closed black necrotic cap scab slimy layers serous-bloody purulent loose, spongy red, firm Epithelium formation visible Pain Signs of infection: III sligt reddening III reddening, swelling, pain III plus fever, leukocytosis Causation General condition / other Management of decubitus [24.25] and a high-dose multivitamin preparation. If normal dietary intake is insufficient or impossible, a fully balanced liquid drinking diet or a parenteral diet should be considered. Adequate fluid intake should also be ensured. Pain: Even if patients do not give expression to their pain or do not react to it, this does not mean that it is not present. Pressure ulcer is usually associated with chronic, diffuse pain affecting the entire body and making every change of position extremely painful. Unfortunately, pain management is still not always accorded the importance demanded by many experts. Usually, such treatment consists merely in the administration of analgesics “on demand”. Pain management, however, should aim to achieve the greatest possible freedom from pain, which requires the regular administration of individually dosed analgesics. Psychosocial assessment: Regardless of whether the decubitus patient is being treated in hospital, in a nursing facility or at home, the same therapeutic principles should be applied to the same standard quality, since otherwise there is little prospect of a cure. The individual psychosocial situation, however, sometimes presents greatly differing baseline conditions in terms of the patient’s ability to fully understand the therapeutic requirements and “cooperate” with the treatment. The aim of the psychosocial assessment is therefore to obtain information about the degree of willingness to cooperate that may be expected from the patient and his/her relatives and what can be done (e.g. by informative interviews, training, use of suitable aids etc.) in order to assure consistent adherence to the treatment and nursing schedule. A realistic assessment of the psychosocial situation is thus of major importance especially in domiciliary care context. Aspects to be evaluated include the patient’s mental state, ability to learn, signs of depression, the social environment, relationship to the caring relatives as well as lifestyle and ethnicity related problems. The resources available for treatment and nursing are also to be evaluated, e.g. the availability and specialized qualification of carers, financial resources, equipment etc. If despite all endeavours it is not possible to create an environment conducive to compliance with the treatment and nursing schedule, transferring the patient to the hospital setting should be considered. Relief of pressure as the basis of all treatment Decubitus ulcers develop as the result of unrelieved exposure of the skin to pressure, leading via ischemic processes to the death of skin cells. The causal principle underlying all decubitus treatments is therefore to restore the blood supply to the affected area of skin by providing complete relief of pressure. Without pressure relief, healing is not possible, and all other activities are pointless. The pressure relief is also to be maintained throughout the entire treatment period. Any exposure to pressure, even for a few minutes, causes new damage and sets back the progress of healing. Transcutaneous oxygen measurements on the skin under simulated and clinical conditions in young volunteers have shown that adequate pressure relief is followed by immediate restoration of the microcirculation and oxygen supply of the skin (Seiler, 1993). When pressure relief is assured, not only oxygen, but also all the other cells necessary for the repair process as well as the biologically important substances such as hormones, enzymes, vitamins and growth factors enter the wound area. For complete pressure relief, the patient is to be positioned such that he/she under no circumstances can come to bear weight onto the wound. Even on a bed fitted with supersoft bedding for pressure relief, the wound area must be kept free from contact. The positioning that is possible depends on the localization of the pressure ulcer (see table). The 30 degree oblique position is regarded as the position involving the lowest risk. Management of decubitus [26.27] The 90 degree oblique positioning should no longer be used, either for prophylaxis or for treatment, because most of the body’s weight then bears on the trochanter. Even before beginning any treatment, therefore, the type of positioning suitable for each patient should be established, and should lead to the establishment of binding guidelines for all those involved in the treatment and nursing of the patient. The correct positioning of the patient depends on the localization of the decubitus ulcer. The basic positioning variants shown here are also suitable for prophylaxis. The different positioning techniques require the combined use of static and dynamic aids. Static aids, such as positioning cushions, should be selected under specific criteria. Their elasticity should be such that it is also preserved under pressure. If the material bunches together, new pressure points result. Especially when using products for free positioning, such as seating rings, superficial pressure distribution must be assured. There is no point in free positioning individual parts of the body and exposing other parts to pressure. The patient must also lie securely and without the risk of slipping on the positioning aids. With inexpert positioning, Decubitus localisation Correct positioning Remarks Right trochanter dorsal position 30 degree oblique position, left all lateral positioning is prohibited Left trochanter dorsal position 30 degree oblique position, right all lateral positioning is prohibited Sacral region 30 degree oblique position, right 30 degree oblique position, left 135 degree positioning Heel 30 degree oblique position, right 30 degree oblique position, left contact-free on special cushions if absolutely contact-free positioning is guaranteed, then also dorsal position is possible Ischial bone 30 degree oblique position, right 30 degree oblique position, left 135 degree positioning sitting prohibited, dorsal position is possible if the patient is also freely positioned the unfavourable weight distribution creates shear forces. For larger decubitus ulcers, patients with multiple risk factors for pressure ulcer, and postoperatively after decubitus surgery, anti-decubitus mattresses of the “low air loss” type are used to ensure absolutely certain pressure relief. A rhythm of two hours is prescribed as the time interval for repositioning. For patients with a very high decubitus hazard it may be necessary to reduce this interval further. A certain amount of experience is generally needed to position patients correctly according to their requirements. It is by no means sufficient simply to slide a cushion somewhere underneath the patient. Nursing personnel should be fully aware that positioning is not intended to provide pressure relief in isolated areas, but is a means of influencing the patient’s body feeling as a whole. In the worst case, inadequate positioning can rapidly give rise to considerable further impairments such as respiratory or circulatory problems, stiffening of joints or contractures. Examples of positionings for pressure relief with the aid of special cushions: Due to its special design, the cushion bed (left) offers effective pressure relief for patients in dorsal position. At the points where the cushions meet, deeper areas are created, so that risk zones such as shoulder blades, the bony profile of the spine, the sacrum, coccyx and heels are positioned almost completely free. For the 30 degree oblique positioning (right) the patient is placed on a soft mattress with the head well supported by a smaller pillow. The 30 degree oblique position is created by placing a long, soft cushion laterally underneath the patient’s back. The knees can additionally be padded with a cushion. Management of decubitus [28.29] Phase-specific moist wound treatment Decubitus ulcer is a secondary healing wound, usually with a poor healing tendency. Providing adequate phase-specific support for wound treatment is thus particularly important. These measures include thorough debridement, continuous cleansing of the wound, conditioning with formation of granulation tissue and the promotion of epithelisation. Also included are measures for preventing and/or controlling infection. Moist wound treatment, in which modern hydroactive wound dressings secure the effectiveness of the method and facilitate its execution, is now regarded as the standard therapeutic approach for cleansing and conditioning wounds and promoting epithelisation. This conservative management of decubitus ulcer by moist treatment may under some circumstances be possible up to Stage III of a decubitus ulcer. Stage IV with muscle and bone involvement and osseous infection, however, is an indication for wound closure by flap plasty following adequate surgical treatment and wound conditioning. Schematic diagram of the timing of the wound healing phases: Inflammatory phase: Cleansing Proliferative phase: Fibroblast migration and formation of granulation tissue Differentiation phase: Maturation and increasing wound contraction / epithelisation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Therapeutic principles and the problems involved in plastic surgical coverage especially in geriatric patients are briefly described from page 37. Cleansing phase and debridement In the cleansing phase, devitalised tissue and microorganisms are removed by autolytic processes. Since the extent of devitalised tissue in a Stage II to III decubitus ulcer is so great that wound cleansing cannot be accomplished by the body’s own resources unaided, however, the wound requires external assistance in the form of thorough debridement. This can be accomplished surgically and/or physically by means of moist wound treatment. The most rapid method of removing necrotic material is surgical debridement with a scalpel or scissors. Necrotic tissue must be surgically excised as soon as possible, since an infection under a necrotic crust can spread unnoticed into deeper tissues. The risk of decubital sepsis or osteomyelitis then increases rapidly. Moreover, necroses prevent healing since they maintain the chronicity of the wound. The more effective the cleansing of the ulcer, the better the quality of the subsequent granulation tissue will be. Hydroactive wound dressings perform valuable service in this respect. Necroses are thus always removed. One exception is necrosis on the heels. This material is only debrided if a prior angiographic examination has ruled out the presence of arterial occlusive disease or a recanalisation operation has been successfully completed. The indication for, type and proper execution of wound debridement are activities reserved for the physician in both the inpatient and outpatient settings. The physician’s obligation to provide a personal service does not however exclude delegating these activities to assistant personnel in certain cases, provided he has made sure that the person entrusted with the task is adequately qualified for the task. Management of decubitus [30.31] The situation, all too common in clinical practice, of someone “snipping around” at an ulcer, should not in fact occur if the legal regulations are properly observed. Surgical debridement should be performed under adequate anesthesia in the operating room because of the pain involved and the possibility of complications. Especially extensive areas of necrosis, but also ulcerations of as yet unknown depth should be debrided under operating room conditions. Debridement at the bedside is increasingly being abandoned. At most smaller ulcers can be debrided at the bedside, provided that adequate pain control is provided, e.g. using local anesthetic creams. If surgical debridement is not possible, for example in very elderly patients in a poor general condition, patients receiving marcumar or heparin therapy, patients with fever, lung inflammation, recent cerebral stroke etc., physical debridement is the alternative. Physical debridement means softening and detaching necrotic material and fibrinous layers with the aid of hydroactive wound dressings. This approach offers several practical advantages: it is selective, because only devitalised tissue is softened and detached, while healthy tissue is not traumatised. Furthermore, the moist wound environment spares the cells responsible for cleansing and proliferation and promotes their activity. The method is also safe and “free from side effects” and easy to perform in all medical and nursing settings, for instance for the domiciliary care of decubitus ulcer. Course of surgical debridement under operating room conditions for a decubitus on the trochanter. The damage was found already to extend much more deeply than suspected of this relatively small lesion. However, one “disadvantage” of the method should be remembered: Physical debridement is not as rapid and effective as surgical debridement and cleansing will take a longer time, a fact which demands a patient and conscientious attitude on the part of the treating person. Various hydroactive wound dressings are available for the practical implementation of physical debridement. The specific modes of action and suitability for different wound conditions are explained in the descriptions of hydroactive wound dressings provided on page 46 onwards. Wound irrigation, for example with Lavasept or Ringer’s solution, may be helpful to support moist wound treatment. This can be done continuously through an indwelling catheter, e.g. for slimy, infectious wounds, or on changing the dressing. Management of decubitus [32.33] Infected decubitus with pus formation; if bacterial toxins are transferred through the lymph tracts and blood stream to other organs, bacteremia or sepsis may result. Infection prophylaxis and control Local infection and peri-ulcer bacterial dermatitis are very common complications. If they are not recognized in time, acute decubital sepsis or unnoticed osteomyelitis can develop. Local infection usually presents with the classical symptoms: reddening and hyperthermia of the area of skin around the ulcer, burning pain on the ulcer floor and periwound area as well as tenderness and edema at the ulcer margin and surrounding area. Expected systemic effects are fever, leukocytosis and elevated C-reactive protein, although these symptoms are often absent in elderly patients. A small tissue biopsy for the bacteriological culture is very helpful, as it allows selective antibiotic therapy to be prescribed if there is a sudden outbreak of decubital sepsis. The prophylactic use of disinfectants often observed in practice is no longer recommended because of their sometimes considerable inhibitory effects on wound healing and the toxic properties of some antiseptic substances. If the ulcer exhibits clinically overt infection and if antiseptics are to be used for a short period, when choosing the antiseptic it should be ensured that it causes no pain and does not considerably compromise wound healing. In particular, an absorption-associated risk should be ruled out, an aspect of particular importance in deep and extensive pressure sores with their protracted treatment period. Even greater problems are presented by the topical use of antibiotics, a practice now regarded as obsolete. It involves the risk of resistance development and a change of the pathogens as well as a greater risk of allergy development than is the case with antiseptics. Furthermore, it is difficult to achieve a sufficient active agent concentration deep inside the wound and to estimate the inhibition of wound healing processes. In patients with severe infections, the systemic administration of antibiotics is indicated, and a microbial determination and resistance test is to be performed if possible to optimize the therapy. The granulation phase Decubitus ulcer is a wound healing by secondary intention, which means that replacement tissue, known as granulation tissue, must be produced to fill the defect. Getting through this phase and supporting the wound in the best possible manner often presents considerable difficulties in practice because it usually requires much time and demands absolute consistency in adhering to the therapeutic concept. Formation of granulation tissue can only take place if the following conditions are fulfilled: The ulcer must remain completely relieved of pressure throughout the entire period so that blood supply to the wound area remains intact and is not impaired by renewed exposure to pressure. The formation of granulation tissue can only take place in a homogeneously moist wound environment. Promoting and maintaining this moist wound environment is therefore the most important task of a wound dressing in this phase. The wound floor must never be allowed to dry out and must be kept permanently moist. If the wound becomes dry, the cells necessary for vascularisation and tissue generation die. A moist wound environment, in contrast, promotes the proliferation of the cells and is thus the best form of care for the granulation tissue. The available hydroactive wound dressings make it possible to keep the wound permanently moist (see description of hydroactive wound dressings from page 46 onwards). The wound must be protected against both chemical and mechanical irritation. Local antiseptics should therefore not be used in this phase. If certain parts of the wound are still in the cleansing phase and if they are still to be disinfected, particular care should be exercised in the areas around the granulation tissue. Management of decubitus [34.35] Mechanical irritations occur when the wound dressing adheres to the wound and newly formed tissue is detached on changing the dressing (= cell stripping). To prevent this considerable disruption of wound healing, the wound dressings used must have atraumatic properties, i.e. they must not adhere to exuding wounds even during prolonged application. All hydroactive wound dressings are atraumatic and thus also offer the desired safety of wound care in this respect. The wound must also be protected against secondary infections, which is why dressings should always be changed under sterile conditions. Dressing changes should also be performed under sterile conditions in the home care delivery setting. If the pressure ulcer is located at a site on the body highly subject to bacterial contamination, e.g. in the sacral region, wound dressings with bacteriaproof surfaces such as the hydrocolloid dressing Hydrocoll provide effective protection against infection. In the endeavour to speed the formation of granulation tissue until the onset of spontaneous epithelisation, a large number of topical therapeutic agents are still used in practice, although scientifically validated studies demonstrating effectiveness are available for hardly any of these preparations. The off-label use of these medicinal products or medical devices without official approval is not without problems and is only justifiable in a few exceptional cases after the currently available therapeutic options have been observed to fail and if their use is expressly allowed by the patient. As a general principle, powders and pastes, but also certain preparations in ointment form, should not be introduced into open wounds. They impede assessment of the wound and can also impair fluid and gas exchange. Moreover, interfering residues frequently remain in the wound when dressings are changed (Winter, 2005). A side effect free substitute for most of these topical wound therapeutic preparations is permanent moist wound treatment. The epithelisation phase Epithelisation by mitosis and migration of epithelial cells from the wound margin completes the wound healing process. In this phase too, keeping the wound surface permanently moist and protecting the young epithelium from cell stripping when changing dressings are the most important aspects of treatment, apart from the fact that complete relief from pressure must continue to be maintained. However, especially decubitus ulcers tend to epithelise poorly. As Seiler et al. were able to demonstrate in 1989, epithelial cells in the immediate vicinity of the ulcer margin show greatly restricted migration. The growth rate was only 2-7 %, whereas healthy skin usually showed a growth rate of about 80 %. Increasing wound contraction and epithelisation from the wound margin due to cell mitosis and migration of epithelial cells complete the wound healing process. A moist wound environment is also required in this phase. During the long chronic course of healing of decubitus ulcer, the constellation is not infrequently seen that the wound margins epithelise and protrude inwards. Since no further epithelisation can then take place from the wound margins, the wound margins should be refreshed by trimming with a scalpel or sharp scissors. Defect coverage by plastic surgery Open wound management for decubitus ulcer is subject to complex problems: It causes pain and impairs the patient’s already debilitated general condition. In addition, conservative treatment is always protracted, which is not only unsatisfactory for the patient and therapist but also places an enormous burden on the health service. A surgical procedure, on the other hand, offers advantages mainly in terms of time, relief of stress on the patient and cost-effectiveness. Whenever possible, therefore, not only younger patients but, increasingly, elderly patients with more severe decubitus ulcers should benefit from this procedure. Management of decubitus [36.37] Defect coverage by plastic surgery can only be fully successful if the patient is optimally prepared for the procedure. Basically, six principles should be followed, and are always implemented in the same order: Pressure relief, debridement, wound conditioning, treatment of risk factors, plastic surgery and continuation care or prophylaxis. The indication for operative closure is dependent on a large number of parameters and is differentiated into vital, absolute and relative indications. Vital indications for an emergency operation are septic decubitus and arrosion bleeding. Although these events are rarely encountered clinical situations, their recognition and immediate treatment can be life saving. An absolute indication for surgery is present when bones or joints are exposed or where the wound extends through to internal organs. Cicatricial cancer developing from long-standing unstable scar areas is also an absolute indication for radical debridement and defect coverage of decubitus. Although cicatricial cancer is very rare, with chronic wounds a biopsy should be taken Plastic surgical coverage of a large sacral decubitus (case study by Jian Farhadi, Basel): Decubitus measuring 7x6 cm after debridement, dissection of a perforator vessel from the direct vicinity of the defect, flap transposed into the defect, gluteus maximus fully intact, problem-free closure of graft site. Flap completely tension-free in the defect after closure of graft site. for histological analysis prior to debridement. Relative indications for surgery are present in Stage III and IV decubitus ulcers to allow early and timely mobilisation of patients, spare them pain and also to shorten the inputintensive period of nursing care. Identification and treatment of factors interfering with wound healing Chronic skin ulcers like decubitus show the typical clinical signs of impaired wound healing in an area which has usually suffered major metabolic derangement. The paramount aim of every ulcer therapy is therefore to restore the physiological conditions, since the repair processes of wound healing can only take place in the correct chronological sequence if physiological conditions resembling the normal situation as closely as possible are present in the wound. If wounds or chronic ulcers heal poorly or not at all, factors delaying healing are present which prevent physiological conditions developing. It is therefore an important aspect of decubitus management to search for such interfering factors in each individual patient. If all the interfering factors can be successfully identified and eliminated and physiological conditions thereby restored, healing can begin. Management of decubitus [38.39] General Factors interfering with wound healing Infections ■ Pneumonia (acute, chronic) ■ Chronic bronchitis ■ Urinary tract infections (acute, chronic) ■ Osteomyelitis ■ Sepsis ■ Local infection of the ulcer ■ Ulcer necrosis ■ Fever ■ Leukocytosis ■ CRP elevation ■ Lymphopenia Malnutrition ■ Catabolism ■ Loss of appetite ■ Dehydration ■ Low-protein diet ■ Protein-free diet ■ Meat-free diet ■ Albumin deficiency ■ Transferrin deficiency ■ Ferritin deficiency ■ Cholinesterase deficiency ■ Low cholesterol ■ Vitamin B12 deficiency ■ Folic acid deficiency ■ Hyperhomocysteinemia ■ Zinc deficiency ■ Iron deficiency ■ Vitamin D deficiency (Source Seiler, 2002) Therapeutic options Therapy of specific underlying causes, whenever possible, or optimized treatment 䊳 Use of antibiotics 䊳 Removing of devitalized tissue (debridement) 䊳 Reduction of fever 䊳 Provision of quality nutrition 䊳 Search for causes of catabolism Search for cause of malnutrition (multifactorial): e.g. gastric ulcer, depression, zinc deficiency 䊳 Causal therapy of malnutrition 䊳 Optimal diet – Proteins: 1.0-1.5 g / kg body weight – Calories: 30-50 kcal / kg body weight – Fats: 30 % of daily calories – Drinking volume: > 20 ml / kg body weight – Vitamin B12: 10 x 1 mg s.c. – Folic acid 1 mg oral – Zinc (org.) 20 mg / day oral – Iron, always intravenous dose depending on severity. – Fully balanced drinking diet up to 1500 ml / d – Multivitamin preparation – Calcium-Vitamin D preparation Diseases ■ Depression, social isolation ■ Anemia ■ Dehydration ■ Diabetes mellitus ■ Immune weakness ■ Heart failure ■ Renal failure ■ Diseases of the gastrointestinal tract ■ Paralysis ■ Immobility ■ Nicotine abuse 䊳 䊳 Medications ■ Corticosteroids ■ Sedative medications ■ Cytostatics ■ Immunosuppressive agents ■ Toxic topical therapeutic agents, e.g. hydrogen peroxide Local interfering factors (local findings) 䊳 Always treat diseases optimally, since diseases lead to catabolism 䊳 Depression: SSRI, care 䊳 Hemoglobin > 11 g / dl 䊳 Drinking volume: > 20 ml / kg body weight 䊳 Diabetes mellitus: optimal glucose levels 䊳 Heart failure, e.g. no leg edema! 䊳 White blood count > 2000 (abs.) 䊳 Serum zinc > 12 mmol / L 䊳 Mobilise Always check topical therapeutics and medications for negative effects on wound healing 䊳 Sedative medications immobilise and impede pressure relief 䊳 Inadequate pressure relief ■ Whitish wound margin ■ Visible, rectangular or round pressure mark at ulcer margin due to excessively thick dressing (> 2 mm) Necrosis ■ Slimy coatings ■ Black necrotic crusts ■ Elevated infectious parameters Local infection ■ Ulcer margin: reddened, hyperthermic, edematous, tender painful ■ Elevated infectious parameters Wound area without granulation, dried out ■ Wound area dried out ■ Dressing adhering ■ After dressing change: bleeding sites, tissue sticking to dressing; pain during and after dressing change Toxic topical therapeutic preparations The following are toxic for tissue: ■ hydrogen peroxide ■ strong disinfectants ■ dyed solutions, etc. Procedure 䊳 䊳 Optimize pressure relief Use only thin, moist dressings Debridement Optimize pressure relief 䊳 Use only thin, moist dressings 䊳 Systemic antibiotics if infectious parameters elevated 䊳 䊳 Debridement Keep permanently moist 䊳 Dressing change 4 x daily 䊳 䊳 Wound irrigation with Ringer’s solution 䊳 Keep permanently moist with suitable hydroactive wound dressings, e.g. hydrocolloid dressings 䊳 䊳 Check wound preparations for topical tissue toxicity Management of decubitus [40.41] 1) Trochanter decubitus with local infection with clearly visible reddening and edema (shiny skin); blackish-yellow necrotic crust, from under which a drop of pus is exuding at the right edge 2) Sacral decubitus with multiple large and deep fistulous tracts; fistulous tracts always indicate the presence of osteomyelitis 3) Local infection with Candida albicans (thrush); typical, the reddening close to the ulcer edge 4) Whitish, hyperkeratotic lesions (incipient callus formation) are a typical sign of insufficient pressure relief on a too firm mattress 1 2 3 4 It is rarely possible to eliminate all interfering factors. For example, the factor “advanced age”, which delays wound healing, cannot be eliminated. Even partially and successively addressing factors that delay healing, however, can provide benefits. The search for interfering factors is a task that should be integrated into the daily routine, since they are either permanently present or, like fever for example, come and go. Usually, several factors delay healing in the same patient. In decubitus, the recurrent, pressure induced ischemia predominates as an interfering factor of the first degree. The most important and most effective means of preventing ischemia and improving the microcirculation in the skin areas at risk remains permanent and complete relief of pressure (see also page 27). Achieving this condition in practice, however, is not always easy. Further local or systemic factors that interfere with wound healing are, to mention only a few: local bacterial and fungal infection, sepsis, osteomyelitis which is often difficult to recognise as such due to the paucity of symptoms, necroses, chronic application of tissue toxic substances, diabetes mellitus, cytostatics, corticosteroids, dried wound dressings, malnutrition with zinc deficiency, protein deficiency, the patient’s mental state, depression, social isolation, fever etc. The elimination of interfering factors thus represents an attempt to restore the physiological wound conditions and address the patient’s needs in a holistic manner. Documentation of decubitus management Exact wound documentation describes all the criteria applied both for therapy planning and estimating the prognosis, monitoring of therapy and the progress of healing. It thus forms the basis of all effective wound management, but should also be seen and accepted as an indispensable instrument for assuring the quality of treatment. Careful recording of the data serves all those involved in delivering wound management as a binding guideline and facilitates adherence to a consistent procedure, starting with a diagnosis of the cause of the wound, establishing an adequate causal therapy and evaluating the state of the wound preparatory to deciding the local wound therapy. As a result, the persons delivering the treatment address the wound related problems in a comprehensive manner. In combination with the search for interfering factors, this improves the prospects of healing the decubitus more rapidly. Management of decubitus [42.43] Wound documentation is also an effective means of reliably estimating progress, stagnation or even setbacks in wound management, and allows therapeutic activities to be “rationally” modified whenever necessary. Above all, wound documentation guarantees the flow of information between the physician and nursing personnel. In this way, it can for example be prevented that conflicting activities may be carried out from one dressing change to another, merely because another person is in charge of wound care. Documented evidence that medical and nursing have been delivered in accordance with current standards has been made a routine obligation regulated by law, and written documentation is thus indispensable for assuring the standards of medical and nursing performance as required by (liability) law. Verbal agreements, made for example on changing from one ward to another or at the ward meeting, are not a suitable means of providing the legally required proof of quality of treatment and care. Whenever possible, data should be entered in the records immediately after the wound treatment has been provided. The state of the wound is then still fresh in the mind of the person concerned and no important information is lost. The records are then always up to date during the course of a shift. The occasionally observed practice of collecting all the entries and entering them all at once just before ward transfer is to be rejected as inadmissible and imprecise. A “suitable” choice of language which exactly describes the state of the wound is of considerable importance for the information value of the documentation. In practice, however, this often causes difficulties and statements are often imprecise. To eliminate uncertainties in this respect, a system of documentation may already contain definitive descriptions of the various parameters which only need to be ticked off. Alternatively, the descriptions to be used can be established in the team and laid down as the “standard” for the documentation which is then binding for the wound team. A particularly effective means of definitively and accurately recording the course of healing is to include photographic documentation. Incorrect interpretations of the type that can arise when wound descriptions are recorded only in writing, are ruled out. As regards photographic documentation, however, certain legal aspects must be taken into account, relating mainly to the patient’s informed consent. As regards practical implementation, it is important that photographs documenting the course of wound healing should always be taken under the same conditions to allow informative comparisons to be made between photographic records taken at different times. Camera and photographic technique are to be chosen such that the images are durable and do not fade and retain their evidential power even after years if necessary. This is assured by the use of digital cameras, which also incur no costs for developing negatives. As regards the aperture setting used, it should be remembered that not only the central wound area but also the surrounding parts of the body should be sharply imaged; a flash may be used if necessary. The background should be as “neutral” as possible, i.e. without structure (right). The photographic apparatus should be as parallel as possible with its exposure level to the photographed object. If the exposure plane and the photographed object are not parallel, the picture will be distorted and will not reproduce the size conditions exactly. Management of decubitus [44.45] Hydroactive wound dressings for phase-specific, moist wound treatment Moist wound treatment is today the standard approach for all secondary healing wounds with tissue formation. It is particularly successful in the management of chronic problem wounds. Practitioners have at their disposal a range of hydroactive wound dressings for moist therapy which cover the entire spectrum of therapeutic requirements in the form of a phase-specific therapeutic system. The scientific principles of moist therapy were established by the studies of G. D. Winter (1962, first published in “Nature”). This author demonstrated that a moist and permeable wound dressing and the associated “moist wound healing” results in more rapid healing than a dry wound environment exposed to the air. Moist wound treatment has positive effects on all phases of wound healing. During the cleansing phase, moist wound dressings achieve a thorough cleansing of the wound and render possible mechanical debridement without damaging cells. Inactivation of immunocompetent cells can also be avoided by the moist environment (Seiler). During the granulation phase, a physiological microclimate similar to a cell culture medium is created within the wound which encourages cellular proliferation and consequently the formation of granulation tissue. Turner / Beatty et. al (1990) have reported that permanent moist therapy causes a significantly more rapid reduction in the size of the wound area and a larger amount of granulation tissue. In the epithelisation phase, the conditions for mitosis and migration of epithelial cells improve under moist dressings. This generally results in more rapid epithelisation with better cosmetic results. Patients frequently report that their pain is relieved under moist wound treatment. In addition, the dressing change itself is atraumatic and causes less pain because modern dressings, as used for moist wound treatment usually do not stick to the wound, i.e. have atraumatic properties. At the same time, this “nonstick” effect eliminates the stripping off of cell layers when the dressing is changed – the undisturbed state of the wound so important for healing is preserved. Tulle bandaging materials adhere to the wound (above), newly formed tissue is also detached when the dressing is changed. This disruption of wound healing can be easily prevented by using atraumatic wound dressings such as gel forming calcium alginate dressings (below). Hydroactive wound dressings [46.47] However, the success of moist wound treatment depends on a critical prerequisite: the wound requires a permanent, uninterrupted, balanced supply of moisture. If at any stage drying out is allowed to occur, the cells inevitably die as a consequence. Further necroses develop and can even eventually deepen the wound. 1 2 3 The principle of action of TenderWet TenderWet – wound pad with superabsorber TenderWet is an extremely effective wound dressing for the treatment of chronic, infected and non-infected wounds during the cleansing phase and at the start of the granulation phase. This high efficiency is attributable to a special principle of action which allows continuous “rinsing” of the wound. TenderWet is a multilayered dressing pad containing superabsorbent polyacrylate (SAP) as the central component of its absorbent core. The non-medicated superabsorber is activated before use with an appropriate volume of Ringer’s solution which is then supplied continuously to the wound over a period of hours. The constant delivery of Ringer’s solution softens, detaches and rinses away necrotic tissue (1). At the same time, however, microbially contaminated wound exudate is absorbed and bound into the absorbent core. This exchange – Ringer’s solution is delivered and proteins are absorbed – functions because the superabsorber has a greater affinity for the protein-containing wound exudate than for the sodium-containing Ringer’s solution (2) and so the wound exudate displaces the solution from the wound pad. As soon as the factors inhibiting wound healing are removed, i.e. the wound has been cleansed of necrotic tissue, detritus and coatings, the conditions necessary for the buildup of granulation tissue are present: proliferative cells can migrate into the wound area and capillary TenderWet 24 and TenderWet are available in a range of sizes and shapes to allow good adaptation to different wound conditions. TenderWet 24 and TenderWet are activated with Ringer’s solution or TenderWet solution directly in the half-opened, sterile peel pack (right). ingrowth is possible (3). The moisture and the electrolytes contained in the Ringer’s solution, such as sodium, potassium and calcium, contribute to the cell growth. TenderWet has no contraindications and can also be used on infected wounds. In certain cases, there is an apparent increase in the size of the wound during the initial cleansing phase with TenderWet. This means that with this method devitalised tissue which was not recognisable as such was removed. In the case of deep wounds, TenderWet should be packed in loosely to ensure the direct contact needed for the fluid exchange. The physical characteristics of the superabsorber in combination with the outer covering of knitted fabric on the wound pad give TenderWet the necessary packing characteristics. With extensive wounds, the TenderWet wound pads should be applied with a slight overlap – the “tiling”. TenderWet comes in a range of presentations and is available in round and rectangular shapes to meet differing application requirements. The classical TenderWet maintains its absorbent-rinsing action for about 12 hours. Dressing changes should therefore be carried out every 12 hours. The frequency of dressing change, however, ultimately depends on the amount of exudate produced by the wound. How much Ringer’s solution is required to activate the dressing Hydroactive wound dressings [48.49] Treatment of a pressure sore on the heel with TenderWet (Case study by Antje Wagner, LeinfeldenEchterdingen): 84-year-old female patient, coronary heart disease, arterial occlusive disease, increasing dementia; decubitus on the left heel. Start of TenderWet treatment on 23 April 99, the necrosis of the heel extended almost as far as the bone (Fig. 1). By 7 May the necrotic tissue on the heel had begun to scale away (Fig. 2). Treatment with TenderWet was continued, and on 22 May the necrotic layers had almost completely come away. The wound is well supplied with blood, some granulation tissue had begun to form (Fig. 3). Consistently continuing this treatment, the heel sore was completely clean by 11 June (Fig. 4). By 22 June the wound was markedly flatter and continued to be well supplied with blood (Fig. 5). Treatment was continued unaltered until the wound healed completely (Fig. 6, 14 August). 1 2 3 4 5 6 depends on the size of the dressing. For easy activation of TenderWet (and also of TenderWet 24), TenderWet Solution is supplied in convenient sizes of 10, 15 and 30 ml. The composition of the sterile, pyrogen-free and isotonic solution corresponds to that of Ringer’s solution. TenderWet 24 is made from the same materials as TenderWet, but is designed so that the absorbent-rinsing action is sustained for up to 24 hours. To protect the dressing from strike through, a water-repellent layer is integrated inside the dressing at the side facing away from the wound. The side of the compress with the integrated protective layer is identified by the presence of parallel coloured strips to allow secure positioning of the wound pad. Because of this protective layer, TenderWet 24 should not be packed into the wound. For greater ease of use, TenderWet and TenderWet 24 are supplied in already activated form as TenderWet active cavity and TenderWet 24 active. These active wound pads are saturated ready to use with Ringer’s solution and can be applied immediately. This dispenses with time consuming preparations. Another advantage of the already activated wound pads is that a much greater volume of Ringer’s solution can be introduced into the absorbent core than is possible with manual impregnation. As a result, the wound can be kept moist for longer. Moreover, the pads are soft and conformable, especially in the case of TenderWet active cavity, which can be used to pack even cavernous wounds without difficulty. In contrast, TenderWet 24 active should not be packed into the wound because of its water repellent protective layer. TenderWet 24 active and TenderWet active cavity are already activated with Ringer’s solution ready for use. Hydroactive wound dressings [50.51] Treatment of a coccyx decubitus with TenderWet (Case study by Eduard Rath, Bernried): 84-yearold female patient, diabetes mellitus, compensated heart failure, poor general condition, pressure sore in coccyx region, S/P femoral neck fracture on both sides. On admission on 18 March 96, the pressure sore was necrotic and purulent with an overt anaerobic infection, surgical debridement was performed on 19 March. On 27 March, treatment of the wound was changed to the dressing pad TenderWet (Fig. 1), activated with an antiseptic instead of Ringer’s solution (Fig. 2). On 9 April, the wound was free from purulent secretions, clean granulation tissue was visible (Fig. 3). Further treatment was administered using TenderWet activated by Ringer’s solution. The buildup of granulation tissue was continuing. The superficially damaged areas of the wound had epithelised well after three and five weeks (Fig. 4/5). TenderWet treatment was continued until 19 June, then changed to Hydrocoll. Wound size 1,5x3 cm on 26 June (Fig. 6). Patient discharged from hospital on 1 July. 1 2 3 4 5 6 The following applies generally to all TenderWet wound pads: They are not self-adhesive and require adequate fixation, e.g. complete-cover dressing retention with elastic adhesive nonwoven fabric (e.g. Omnifix) or elastic conforming bandages (e.g. Peha-crepp, Peha-haft). Sorbalgon – calcium alginate dressings with excellent conformability Sorbalgon is the wound dressing ideally suited for cleansing and for supporting the buildup of granulation tissue in cavernous wounds and wounds in difficult anatomical sites. By virtue of its excellent packing characteristics, Sorbalgon also provides effective cleansing and conditioning in deep wounds. In the treatment of venous ulcers, Sorbalgon is especially indicated during the period of continuation treatment in patients who have undergone surgical debridement of necrotic tissue. Sorbalgon is a nonwoven dressing made of high-quality calcium alginate fibres which are introduced in the dry state into the wound (1). As they absorb sodium salts, present for example in blood and wound exudate, the fibres start swelling and undergo transformation into a hydrophilic gel which expands and fills out the wound (2). Since Sorbalgon adapts closely to the wound surfaces, microorganisms are also taken up deep inside the wound and are reliably absorbed into the gel matrix (3). This provides efficient microbial reduction and helps avoid recontamination. Wounds are swiftly cleansed, and Sorbalgon has therefore proved especially successful in the treatment of chronic and infected wounds. With its gel-like consistency, Sorbalgon also acts like a moist dressing that prevents the wound from drying out. The dressing creates a microclimate favourable for wound healing, promotes the formation of granulation tissue and keeps the wound surfaces supple. 1 2 3 The principle of action of Sorbalgon Hydroactive wound dressings [52.53] Treatment of a decubitus in the sacral region, Stage III, with Sorbalgon (Case study by Friedhelm Lang, Leonberg): Findings on admission (Fig. 1), the decubitus underwent surgical debridement. A large amount of pus was discharged (Fig. 2), a further fistulous tract had to be incised (Fig. 3). The wound was packed with Sorbalgon while the patient is still in the operating room (Fig. 4). At the first dressing change, small necrotic residues were removed with a scalpel (Fig. 5). The wound was again loosely packed with Sorbalgon (Fig. 6), and on the 11th day after debridement, the defect was well supplied with blood (Fig. 7). Four weeks later, abundant granulation tissue had formed, the wound was clean and infectionfree (Fig. 8). With the above wound status the patient was transferred back to the nursing home from where she was referred. 1 2 3 4 5 6 7 8 Sorbalgon has excellent conformability qualities and thus also provides effective cleansing and conditioning in deeper wounds. Sorbalgon is available as a dressing and ribbon. Sorbalgon’s gel-forming properties prevent it from sticking to the wound and dressing changes involve little pain. However, complete gelatinisation of the calcium alginate fibres requires the presence of sufficient exudate. If cavernous wounds with little exudate have to be packed, Sorbalgon should be moistened with Ringer’s solution. Any fibres remaining in the wound can be rinsed out with Ringer’s solution, otherwise the gel plug is removed from the wound using forceps. The frequency of dressing change depends on the individual wound situation. In the wound cleansing phase, 1 to 2 dressing changes may be required depending on the amount of exudation. Later, as granulation tissue forms, a dressing change every two to three days may be sufficient. Sorbalgon is available in two sizes as square dressings. Sorbalgon T is available as a ribbon. Sorbalgon dressings loosely packed in (left) and their transformation into a gel-like structure on contact with exudate (right) Hydroactive wound dressings [54.55] Treatment of decubitus in the sacral region, Stage III, with Sorbalgon (Case study by Friedhelm Lang, Leonberg): Findings on admission (Fig. 1), the decubitus was treated with a gauze swab. After its removal, the necrotic layer was visible on the sacral bone (Fig. 2). 10 days after surgical debridement and treatment with Sorbalgon, granulation began (Fig. 3/4). Continued buildup of granulation tissue (Fig. 5). Wound status 20 days after debridement and Sorbalgon treatment (Fig. 6), discharge to domiciliary care. 1 2 3 4 5 6 PermaFoam – hydroactive foam dressing The PermaFoam foam dressing is indicated for non-infected wounds with moderate to heavy exudate in the cleansing phase and during the granulation phase. Its therapeutic action is based on its special pore structure. PermaFoam is a combination of two differently structured foams that are connected with each other by a special form of lamination. The absorbent layer of PermaFoam consists of hydrophilic polyurethane polymers that can store up to nine times their own weight of liquid in their polymeric chains. The polyurethane matrix has a unique pore gradient: the large pores on the wound side become progressively smaller in the direction of the outer coating layer, which produces strong vertical capillary action. The outer PermaFoam layer consists a flexible, close-porous polyurethane foam and is semipermeable, which means bacteria-proof but permeable to water vapour. The hydrophilic foam dressing PermaFoam with its convincing physical mode of action extends the range of treatment options for chronic wounds. This material combination and design results in product characteristics which can counteract the maceration problems often observed with chronic wounds: via the strongly marked vertical capillarity, the surplus aggressive wound exudate is quickly drawn up to underneath the outer layer. The large foam pores on the wound side ensure that viscous exudate and detritus are also absorbed without blocking the pores. When absorbing the wound exudate, the polyurethane foam swells slightly which ensures the contact necessary to draw off discharges from the wound floor. Hydroactive wound dressings [56.57] Treatment of toilet seat-shaped decubitus due to sitting for hours on the toilet, 83-year-old female patient (Case study by Friedhelm Lang, Leonberg) (1) Findings on admission (2) State of decubitus after surgical debridement (3) – (6) Wound cleansing and wound conditioning were performed using the foam dressing PermaFoam, continuous healing progress was observed. (7) and (8) Clean granulation tissue rapidly formed during PermaFoam treatment. Epithelisation of the defect was equally rapid from the wound margin, and the size of the defect steadily decreased. Remarkably, despite the patient’s poor general condition we did not have to accept any stagnation or setbacks in the treatment course. On the 42nd postoperative day treatment was changed to Syspur-derm, until the ulcer was completely closed with stable epithelial tissue capable of loading within 65 days. 58 1 2 3 4 5 6 7 8 The absorbed wound exudate then spreads out laterally under the outer layer. In this regard, it is also important that PermaFoam has – mainly due to the special pore structure – a high retention capacity for fluids. Even when pressure is applied from outside by, for example, a pressure bandage, the exudate is retained in the foam. Also relevant is the fact that the absorbent capacity of PermaFoam is only slightly reduced even under the pressure of a compression bandage. For example, under a pressure of 42 mmHg, the absorbent capacity is reduced by only 12 % compared with the pressure-free condition. The therapeutic efficacy of PermaFoam derives from its special pore structure: large pores on the wound side become progressively smaller in the direction of the outer coating layer, which produces strong vertical capillary action. As a result, exudate is rapidly absorbed deep inside the absorbent pad, but also provides high retention for reliable fluid binding. Taken together, all these characteristics result not only in the desirable rapid regulation of exudation, but also protect the wound margins from maceration because the absorbed wound exudates are not pressed back into the wound again. In addition, the high permeability of the outer layer to water vapour ensures a well-balanced moist microenvironment for the wound, which further supports the healing process. PermaFoam is atraumatic, sticking to the wound and growth of tissue into the foam structure are minimised. Due to the high absorbent capacity and the very good retention, PermaFoam can – even with profuse exudation (when no complications exist) – remain on the wound for several days. Hydroactive wound dressings [58.59] 2 1 3 Specially for decubitus treatment, PermaFoam is also available cut to size for specific therapeutic requirements: 1) PermaFoam sacral for the sacral region 2) PermaFoam cavity for packing deep wounds 3) PermaFoam concave for elbows and heels PermaFoam is soft and flexible and therefore clings well to the wound contours. The dressing is held in place with elastic dressing retention bandages (e.g. Peha-haft) or over the entire area with adhesive elastic nonwoven fabrics (e.g. Omnifix elastic). The product version PermaFoam comfort is designed for an easy fixation with an adhesive border. The used adhesive is gentle on the skin. PermaFoam is available in a variety of versions and sizes. Hydrocoll – absorbent hydrocolloid dressing Hydrocoll is a self-adhesive, absorbent hydrocolloid dressing for cleansing and conditioning of non-infected wounds with moderate to heavy exudate. The term “colloid” comes from the ancient Greek and means a substance which is integrated in a very finely dispersed form in a matrix. Hydrocoll therefore consists of hydrocolloids capable of absorbing and swelling and are incorporated in a self-adhesive elastomer. A semipermeable film serves to prevent bacterial and moisture penetration. The principle of action of Hydrocoll The central feature of the mechanism of action of Hydrocoll is the hydrocolloids incorporated in the backing layer. On absorbing wound exudate they swell to form a gel which expands into the wound and maintains a moist wound environment. The gel remains absorbent until the hydrocolloids are saturated. During the swelling process the absorbed wound exudate, which is always contaminated with detritus, bacteria and their toxins, is securely retained within the gel structure. Hydrocoll is a self-adhesive, absorbent hydrocolloid dressing for cleansing and conditioning non-infected wounds with moderate to heavy exudate. For practicable and economical use, Hydrocoll is available in a variety of shapes and presentations: (1) and (2) Hydrocoll concave with perfect fit for elbows and heels (3) and (4) Hydrocoll sacral specially for wound treatment in the sacral region Figures (5) – (8) show excerpts from the course of wound healing of a Stage II decubitus with blistering on the left heel. Wound care was provided with Hydrocoll and was uncomplicated. Because of its high absorbent capacity, Hydrocoll could be left on the wound for several days which made treatment easy and also cost-effective because of the reduced number of dressing changes. (case study by Gabi Michl, Kötzting) 1 2 3 4 5 6 7 8 Hydroactive wound dressings [60.61] The adhesive power of the elastomer allows Hydrocoll to be applied to the wound like an adhesive plaster. When the gel forms, the adhesive power on the wound surface disappears, leaving Hydrocoll fixed only on the intact peri-wound area in a manner atraumatic to the wound. Hydrocoll is manufactured using hydrocolloids with especially good absorbent and swelling properties, and which also have the characteristic of retaining a compact gel structure. Although Hydrocoll expands into the wound, in the gelatinised state it can be removed from the wound as an entirely intact dressing. Hardly any gel remnants remain in the wound, making it only seldom necessary to irrigate the wound to remove gel residues of pus-like consistency. This makes dressing change easier and more pleasant. Moreover, a reliable wound assessment can be made immediately. The mechanism of action of Hydrocoll is effective in all the phases of wound healing: Since microbially contaminated wound exudate is quickly taken up into the hydrocolloid structure of the dressing by the absorbent and swelling process, the wound is rapidly and effectively cleansed. As general studies have shown, the microcirculation in the wound area also improves with progressive cleansing. The body’s own cleansing mechanisms are reactivated especially in chronic wounds in which the cleansing process is stagnating. During the granulation phase, the moist wound environment maintained by Hydrocoll stimulates the formation of granulation tissue. With Hydrocoll, the balanced moist wound environment can also be maintained without difficulty over prolonged periods and the granulation tissue is reliably prevented from drying out. In the epithelisation phase, the cell-friendly moist wound environment promotes mitosis and migration of the epithelial cells. In addition, undesirable scab formation which could delay healing is prevented. The bacteriaproof and waterproof outer layer forms a reliable barrier against microorganisms and protects the wound from dirt and moisture. Mobile patients can shower with the dressing in place. The “Hydrocoll thin” version is specially suited for already epithelising wounds. Hydrosorb – transparent hydrogel dressing Hydrosorb is the ideal wound dressing that keeps the necessary degree of moisture required by granulation tissue and fresh epithelium and is best suited for phasespecific continuation treatment after initial wound treatment with TenderWet, Sorbalgon or PermaFoam. Hydrosorb is a ready-to-use gel sheet dressing made of absorbent polyurethane polymers which hold a high water content of 60 %. This allows Hydrosorb to provide the wound with moisture – actively, with immediate effect and over several days (1). At the same time, Hydrosorb absorbs excess secretion which is then trapped within the matrix of the gel. This humidity-exudate exchange ensures the optimum moisture level for wound healing and thus accelerates granulation and epithelisation (2). Additionally, the bacteriaproof and waterproof outer surface of Hydrosorb provides safe protection from secondary infections. 1 2 The principle of action of Hydrosorb Hydroactive wound dressings [62.63] Hydrosorb does not stick to the wound and its removal creates no risk of causing wound irritation, even after long periods of application. Hydrosorb can be removed as an entirely intact dressing because the gel matrix does not dissolve as a result of absorbing wound secretions. No remnants are left on the wound, and an assessment of the wound condition can be done safely without prior rinsing. The transparency of Hydrosorb is particularly advantageous in the everyday use of this dressing because it is permanent, even after the dressing has been on the wound for longer periods. This transparency makes it possible to inspect the wound at any time without requiring a dressing change. Thus, the wound is allowed to rest – which is so important for healing – and great cost-effectiveness is achieved due to longer time intervals between dressing changes. Hydrosorb is available in two designs as Hydrosorb and Hydrosorb comfort. Both hydrogels are based on the same physical principle of action but differ in their respective mode of fixation. Hydrosorb does not feature a self-adhesive fixation border and is usually secured by using a conforming bandage or a compression bandage. Hydrosorb comfort is provided with a hypo-allergenic adhesive film border around the edges for secure, bacteriaproof fixation. This, together with the bacteriaproof and waterproof covering layer of Hydrosorb comfort, simplifies its use and greatly facilitates daily hygiene. The transparency of Hydrosorb is important for its economical use. The wound can be inspected through the dressing at any time, and Hydrosorb can therefore be left on the wound for days at a time, and fewer dressing changes are needed. 1 2 3 4 Example of a Hydrosorb comfort application (Case study Friedhelm Lang, Leonberg): 88-year-old patient with decubitus of the heel. Ulcer status at the start of treatment exclusively with Hydrosorb comfort on 10 August 1998 (Fig. 1). After 10 days of treatment, fresh red granulation with beginning epithelisation (Fig. 2-4). The patient was discharged after 16 days. Hydroactive wound dressings [64.65] TenderWet Sorbalgon Product characteristics wound pad with absorbentrinsing core made of superabsorbent polyacrylate is activated before use with Ringer’s solution, which is then given off to the wound in exchange for wound exudate excellent conformability, non-medicated, active agent free calcium alginate dressings that transform into a moist gel on contact with wound secretion; the swelling process also securely traps microorganisms in the gel structure. Properties and main uses due to continuous delivery of Ringer’s solution and simultaneous absorption of microbially contaminated exudate (= absorbentrinsing effect), rapid active wound cleansing and promotion of the proliferation of the tissue cells, for the treatment of chronic, infected and non-infected wounds during the cleansing phase and the beginning of the granulation phase high absorbency with efficient cleansing action, after transforming into gel keeps the wound moist, promotes formation of granulation tissue, due to excellent conformability ideal for cleansing and conditioning of deep and cavernous, infected and non-infected wounds and after surgical debridement Presentations TenderWet 24 active, sterile, Ø 4, Ø 5,5, 4x7, 7,5x7,5, 10x10 and 7,5x20 cm; TenderWet active cavity, sterile, Ø 4, Ø 5,5, 4x7, 7,5x7,5, 10x10 and 7,5x20 cm; TenderWet 24, sterile, Ø 4, Ø 5,5, 7,5x7,5 and 10x10 cm; TenderWet, sterile, Ø 4, Ø 5,5, 7,5x7,5 and 10x10 cm Sorbalgon, sterile, 5x5, 10x10 and 10x20 cm; Sorbalgon T ribbons, sterile, 1 g/30 cm and 2 g/30 cm Products for hydroactive wound management PermaFoam Hydrocoll Hydrosorb hydroactive foam dressing made of differently structured foams with high vertical capillary action and retention self-adhesive hydrocolloid dressing with particularly absorbent and swellable hydrocolloids, combined with semipermeable bacteriaproof and waterproof cover layer transparent gel made of absorbent polyurethane polymers with a high integrated water content of about 60 %, combined with semipermeable, bacteriaproof and waterproof cover layer rapid regulation of wound exudates, protects wound margins from maceration, particularly suitable for treatment of venous ulcers in combination with compression treatment for the care of up to 2nd degree burns. The specific cut-to-size parts are used for deeper wounds or problem zones in difficult anatomical sites provides good cleansing, improves microcirculation in the wound area, promotes formation of granulation tissue, no sticking to the wound, in the gelatinised state can be removed from the wound as an entirely intact dressing, especially suitable for conditioning non-infectious wounds with moderate to slight exudate supplies the wound with moisture from the outset, its transparency allows inspection of the wound at all times without dressing change (= highly economical due to prolonged dressing change intervals), ideal for keeping granulation and epithelial tissue moist after treatment with TenderWet, Sorbalgon or PermaFoam therapy PermaFoam, sterile, Ø 6, 10x10, 10x20, 15x15, 20x20 cm; PermaFoam comfort, sterile, 8x8, 11x11, 10x20, 15x15, 20x20 cm; PermaFoam sacral, sterile, 18x18, 22x22 cm; PermaFoam concave, sterile, 16,5x18 cm; PermaFoam cavity, sterile, 10x10 cm Hydrocoll, sterile, 5x5, 7,5x7,5, 10x10, 15x15 and 20x20 cm; Hydrocoll sacral, sterile, 12x18 cm; Hydrocoll concave, sterile, 8x12 cm; Hydrocoll thin, sterile, 7,5x7,5, 10x10 and 15x15 cm Hydrosorb, sterile, 5x7,5, 10x10 and 20x20 cm; Hydrosorb comfort, sterile, 4,5x6,5, 7,5x10, 12,5x12,5 and 21,5x24 cm Hydroactive wound dressings [66.67] Wound dressings for chronic problem wounds / decubitus ulcers Wound cleansing Necrosis Infection Fibrin layer Stage I* and II Exudate ++ TenderWet 24 active 䡲 TenderWet 24 active 䡲 Sorbalgon 䡲 Atrauman Ag with absorbent wound dressing Intact peri-wound area 䡲 PermaFoam comfort 䡲 PermaFoam sacral 䡲 PermaFoam concave 䡲 TenderWet 24 active Pre-damaged peri-wound area 䡲 PermaFoam Exudate + 䡲 TenderWet 24 active 䡲 Atrauman Ag with absorbent wound dressing 䡲 TenderWet 24 active Stage III and IV Exudate ++ TenderWet active cavity 䡲 TenderWet active cavity 䡲 Sorbalgon/Sorbalgon T 䡲 Atrauman Ag with absorbent wound dressing 䡲 TenderWet active cavity 䡲 PermaFoam cavity 䡲 Sorbalgon/Sorbalgon T Exudate + 䡲 TenderWet active cavity 䡲 Atrauman Ag with absorbent wound dressing 䡲 TenderWet active cavity Granulation Epithelisation Intact peri-wound area 䡲 PermaFoam comfort 䡲 PermaFoam sacral 䡲 PermaFoam concave Pre-damaged peri-wound area 䡲 PermaFoam Intact peri-wound area 䡲 Hydrocoll thin 䡲 Hydrosorb comfort 䡲 Hydrofilm Pre-damaged peri-wound area 䡲 Hydrosorb Intact peri-wound area 䡲 Hydrocoll 䡲 Hydrocoll sacral 䡲 Hydrocoll concave Pre-damaged peri-wound area 䡲 Hydrosorb 䡲 PermaFoam cavity 䡲 Sorbalgon/Sorbalgon T 䡲 PermaFoam cavity Further products Cosmopor sterile Self-adhesive wound dressing with high absorbency and good padding effect for postoperative wound management and for sterile treatment of minor injuries Hydrofilm plus Self-adhesive, waterproof, transparent film dressing with good absorbency and padding effect for postoperative management of lightly exuding wounds and for protection against secondary infections Dressing retention Normal skin: Omnifix elastic, Omniplast, Omnisilk, Peha-haft, Stülpa-fix Sensitive skin: Pehalast, Omnipor, Peha-crepp, Extremities: Peha-haft**, Pehalast, Stülpa-fix Sacral region: Omnifix elastic, Molipants (Inco-System), Stülpa-fix * Skin protection for Stage I Hydrocoll thin, Hydrofilm, Menalind professional skin protection foam Intact peri-wound area 䡲 Hydrocoll thin 䡲 Hydrosorb comfort 䡲 Hydrofilm Pre-damaged peri-wound area 䡲 Hydrosorb ** Warning: Since Peha-haft is a cohesive conforming bandage, it should be used with care in patients with disturbed blood circulation. Do not apply too tightly. Hydroactive wound dressings [68.69] Nursing activities for decubitus prophylaxis The activities required for the prevention of pressure ulcers can be divided into five main categories: Recognise the risk of pressure sore! The following simple rule can be applied: The less mobile a person, the greater the risk of a pressure ulcer developing. If risk factors such as fever, incontinence or a debilitated general condition are also present, great alertness is needed. In daily nursing activities, the extended Norton scale has proved a reliable instrument for estimating the risk of decubitus (see also page 17). Observe the skin! The patient’s skin should be inspected at least once daily for signs of incipient exposure to pressure. The first signs are white or red, sharply defined areas of skin (see page 16). The classical pressure ulcer localisations such as the sacral region, trochanter and heels should be examined especially closely. At the first signs, pressure relief should be commenced immediately. Pressure-relief positioning! There is only one means of effectively preventing pressure sores: eliminate exposure to pressure. This can be achieved by repositioning, soft positioning or free positioning; these individual expedients can also be combined to achieve the greatest degree of safety. Repositioning in effect replaces the lacking or inadequate movement of the body. Patients are usually repositioned in a two-hourly rhythm. If the risk is particularly great, Schematic diagram of pressure distribution on a firm mattress (top) and the pressure relieving effect of a soft mattress (bottom) however, it may be necessary to shorten this time interval. Conversely, when there is a low risk of pressure ulcer, it is possible to extend the repositioning interval through the additional use of extremely soft positioning. The 30 degree oblique position, alternately right or left, is now preferred as the positioning that involves the lowest risk (see also page 28). The 90 degree lateral position, on the other hand, is now considered obsolete, because most of the body’s weight is then bearing on the trochanter. Soft positioning is performed with the aid of special mattresses, support surfaces and pillows into which the patient can sink down. The bearing pressure of the body is then distributed over a greater area, resulting in pressure relief. In free positioning, sites of the body that are particularly at risk, such as the heels, are positioned free of contact and are therefore completely relieved of pressure. Safely usable positioning aids are also available for free positioning. Prophylactic activities [70.71] Mobilise the patient! Immobility is the greatest risk factor. Everything possible should therefore be done to mobilise the patient as rapidly as possible or maintain any residual mobility, e.g. by performing sitting exercises and passive and active movements in bed; for severely ill and absolutely immobile patients, repositioning every two hours is also a valuable form of mobilisation. Intensify skin care! Healthy skin is more resistant to pressure stress than skin with existing damage, and should therefore be given particularly close attention in the classical pressure sore areas. Especially dried skin of the elderly should not be dried further during washing and should be protected by the use of cleansing and conditioning preparations with highly oil-restoring additives. To stimulate blood circulation of the healthy skin, light massages and embrocations may be used, but icing and fanning of the skin should be avoided. If alcohol-containing embrocations are used, the skin should be treated with an oil restorative afterwards to prevent drying out. Skin macerations due to incontinence can be prevented by using adequate incontinence products and careful skin care. Supplementary aids for treatment and nursing care Aids for dressing change A large number of practical aids are available to make the process of changing dressings safer and easier: Disposable gloves in various qualities reflecting the different requirements for wound management, sterile and unsterile, cotton-tipped applicators, tweezers, disposal bags for contaminated material, drapes to create sterile working surfaces, mouth and nose protectors etc. A number of fixation aids are also available for the retention of wound dressings in different therapeutic situations: The nonwoven dressing retention sheet plaster Omnifix elastic, for example, is ideal for wide-area coverage. The transparent and bacteriaproof film dressing Hydrofilm, on the other hand, is highly suitable for full-area coverage of wounds in areas exposed to microbial contamination, such as the sacral region, and offers safe protection against secondary infections. The cohesive elastic conforming bandage Peha-haft is indispensable for the fixation of, for example, TenderWet on the heels. Peha-haft is easy to apply even on this difficult to dress part of the body and is non-slip due to its cohesive coating. If fixation tapes are required, the skin-friendly surgical adhesive tapes Omniplast, Omnisilk, Omnipor and Omnifilm are outstandingly suitable for this purpose. Caution: As a cohesive dressing retention bandage Peha-haft is to be used with care in patients with blood circulation disorders and should not be applied too tightly! Supplementary aids [72.73] 1) Peha-soft powder-free: Disposable gloves made of latex, one example of the wide range of disposable gloves 2) Cotton buds: in various styles, useful aids for wound cleansing 3) Peha disposable forceps: made of plastic anatomically shaped, indispensable for dressing change 4) ValaComfort mask: mouth and nose mask made of nonwoven, for infection prophylaxis on dressing change 5) Foliodrape drapes: in various qualities, for sterile draping of patients and surfaces 6) Pagasling: twisted gauze swabs of high absorbency, ideal for cleansing wounds 7) Omnifix elastic: skin friendly nonwoven fixation sheet for simple full-area dressing retention also on conical parts of the body 8) Hydrofilm: film dressing for full-area coverage of wounds 9) Peha-haft: cohesive-elastic conforming bandage, stays reliably in place without end fixation and is particularly economical in use 10) Omnipor: hypoallergenic surgical adhesive tape made of nonwoven, suitable for very sensitive skin 1 2 3 4 5 6 7 8 9 10 Menalind professional – care and protection of the skin The importance of intensive skin care for maintaining the health especially of elderly skin cannot be emphasized enough. The Menalind cleansing, conditioning and protection products offer a reliable form of care because all the products are specifically formulated to meet the needs of the skin of the elderly. The Menalind ingredients such as oil-restoring substances, D-panthenol and creatine support the regeneration of the skin and promote the maintenance of its health. All products are clinically tested. Menalind professional comprises three product lines: 䡲 Menalind professional cleansing products – wash lotion, shampoo, skin care bath, skin cleansing foam, moist skin care tissues and body cleansing wipes 䡲 Menalind professional care products – hand cream, skin fluid, skin care oil, body lotion and oil bath 䡲 Menalind professional – skin protection foam, skin protection cream and skin protection oil spray Supplementary aids [74.75] The HARTMANN Inco System helps prevent skin traumatisation Urinary incontinence places great stress on the skin for a variety of reasons and is thus a risk factor for the causation of pressure ulcer. Moisture and the aggressive breakdown products of urine irritate and soften the skin. The pH becomes increasingly alkaline, the skin becomes increasingly permeable to water soluble substances, and bacterial contamination increases. An important goal of incontinence care is thus also to prevent this damage to the skin. The skin must therefore be kept as dry as possible, which can only be assured by using high quality incontinence products. All incontinence products from HARTMANN, through their material components and product design, offer maximum safety: The odour-binding superabsorbent core rapidly absorbs liquid and the fluid distribution layer made from the special Dry-Plus nonwoven protects against rewetting and keeps the skin drier. The HARTMANN Inco system includes products for all degrees of severity of incontinence, with the aim of ensuring patient individualized and economical care under all conditions: MoliMed for men incontinence pads for men, MoliMed absorbent pads for slight incontinence, MoliForm incontinence pads for slight, moderate, severe and very severe incontinence, MoliForm for men incontinence pads, MoliCare all-in-one incontinence briefs for severe and very severe incontinence, MoliCare Premium all-in-one incontinence briefs with breathable nonwoven fabric layer in the hip region, MoliCare Med all-in-one incontinence briefs containing an inner top layer of panthenol-treated nonwoven fabric and MoliCare Mobile incontinence pants which can be pulled on and off like normal underwear. Glossary and list of key terms A D H Acute ➞ sudden, rapidly occurring onset of the disease Debridement ➞ 31 Hydroactive wound dressings ➞ 46 f Adjuvant ➞ supporting helping, e.g. adjuvant therapy Affinity ➞ tendency (attraction) towards someone or something Age of the patient ➞ 14 Anamnesis ➞ systematic questioning (of the patient) Anemia ➞ lack of blood deficiency of red blood corpuscles or blood pigment (haemoglobin) Decubitus classification ➞ 18 Decubitus localisation ➞ 9 Decubitus prophylaxis ➞ 70 Hydrocoll (hydrocolloid dressing) ➞ 60 Decubitus risk ➞ 10 f Hydrophilic ➞ water-absorbing, water loving Defect coverage, plastic surgery ➞ 37 Hydrosorb (hydrogel dressing) ➞ 63 Degree of severity, Stage I ➞ 18 I Degree of severity, Stage II ➞ 18 Immobility, total ➞ 12 Immobility, elative ➞ 12 Incontinence ➞ 13 Assessment of the patient’s status ➞ 22 f Degree of severity, Stage III ➞ 18 Autolysis ➞ ability of dying cells to digest themselves by releasing certain enzymes without the involvement of bacteria Degree of severity, Stage IV ➞ 19 Induced ➞ introduce, instigate med.: cause, trigger Documentation ➞ 43 Infection control ➞ 34 Dressing change ➞ 73 Infection prophylaxis ➞ 34 E Insufficient blood supply ➞ 13 Epithelisation phase ➞ 37 Irreversible ➞ cannot be changed back, cannot be undone C Cachexia ➞ emaciation due to severe loss of weight, decay of strength resulting from certain underlying diseases Causal ➞ the reason for Estimation of decubitus risk ➞ 16 Inco-System ➞ 76 Ischemia ➞ emptiness of blood F M Cleansing phase ➞ 31 Factors interfering with wound healing ➞ 39 f Maceration ➞ swelling, softening e.g. of wound margins Convex ➞ bulging, rounded Fever ➞ 13 C-reactive protein (CRP) ➞ acute phase protein formed by the liver, used as a parameter of inflammation G Malnutrition ➞ incorrect or deficient diet Causes of pressure ulcer ➞ 6 f General physical condition ➞ 22 Granulation phase ➞ 35 Management of pressure ulce ➞ 20 f Menalind professional ➞ 75 Glossary and index of key terms [76.77] Migration ➞ travelling, moving med.: cell migration Mitosis ➞ process of cell division in somatic cells Multimorbiditiy ➞ simultaneous presence of several diseases N Nursing activities ➞ 70 Nutritional status ➞ 24 O Obsolete ➞ out of date, no longer current no longer complying with the rules of medical science Operation-specific risks ➞ 14 Overt ➞ clearly evident, obvious med.: the becoming evident of a disease due to the corresponding symptoms P Pain ➞ 26 Pathological ➞ disease related, deviating from normal Patient status ➞ 22 PermaFoam (hydroactive foam dressing) ➞ 57 Pressure relief ➞ 27 f Proliferation ➞ growth of tissue by propagation resulting from inflammatory processes e.g. during wound healing following the inflammatory phase Psychosocial assessment ➞ 26 R Recurrent ➞ occurring again and again med.: relapsing of a disease after it has healed Relevance ➞ importance, significance of a thing or circumstances Risk factors ➞ 10 f S Sites of predilection ➞ sites of the body preferentially affected by a disease process Skin care and protection ➞ 75 Sorbalgon (highly comfortable calcium alginate dressings) ➞ 53 T Tangential ➞ touching a curved surface or line Tenderness ➞ pain caused by mechanical pressure on part of the body, diagnostically useful TenderWet (wound pad with superabsorber) ➞ 48 Toxic ➞ poisonous W Wound dressing ➞ 46 f Wound treatment ➞ 30 f References Farhadi; J., Pierer, G.: Plastisch-chirurgische Konzepte zur Deckung von Dekubitalulcera (II), in HARTMANN WundForum 1/2005 Lang, F., Röthel, H.: Das Dekubitalulcus – Ursachen, Prophylaxe und Behandlung, in HARTMANN WundForum 2/1999 Seiler, W. O.: Dekubitus-Pathogenese und Prophylaxe (I), in HARTMANN WundForum 3/2002 Seiler, W. O.: Dekubitustherapie mit System (II), in HARTMANN WundForum 4/2002 Seiler, W. O., Stähelin, H. B.: Dekubitus, in Sedlarik, K. M. (Hrsg.): Wundheilung, Gustav Fischer Verlag, Jena/ Stuttgart, 1993 Seiler, W. O., Seiler, D. W.: Katabolismus: Hauptstörfaktor der Wundheilung im Alter, in HARTMANN WundForum 1/2001 Winter, H., Nusser, B.: Problemwunden – Herausforderung für Medizin und Pflege (V), in HARTMANN WundForum 1/2005 References [78.79] List of illustrations Brookes, A. / Corbis (p. 1) Farhadi, J. (p. 38) Feingersh, J. / Corbis (p. 6) Lang, F. (p. 20, 22, 33, 47, 54, 56, 58, 65) Lück GmbH, Bocholt (p. 29) Michl, G. (p. 61) Rath, E. (p. 52) Seiler, W. O. (p. 42) according to illustrations from Straub, G. in: Die Schwester/Der Pfleger 7/84 (p. 11) Wagner, A. (p. 50) All other illustrations from the archive of PAUL HARTMANN AG medicaledition PAUL HARTMANN Asia-Pacific Ltd. 16/F Unit 1608 Kerry Cargo Centre 55 Wing Kei Road Kwai Chung NT Hong Kong ISBN 3-929870-44-4 At a time of rapidly evolving scientific knowledge, information must above all be up to date. With this in mind, this series of books aims to be a source of advice not only for experienced workers. Those who are approaching new areas of medicine and nursing for the first time are shown modern treatment methods and are given useful tips. HARTMANN medicaledition – Phase-specific wound management of decubitus ulcer PAUL HARTMANN AG Unit P2 Parklands Heywood Distribution Park Pilsworth Road Heywood, Lancs OL10 2TT United Kingdom Phase-specific wound management of decubitus ulcer The HARTMANN medical edition series of publications deals with current subjects from the areas of medicine and nursing. They emphasise not only basic knowledge, but also present specialist and interdisciplinary developments. The information goes beyond the products and is particularly important. B34 (0106) 086 XXX/X PAUL HARTMANN AG P.O. Box 14 20 D-89504 Heidenheim Germany Wound Management